Laserfiche WebLink
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UST/PIPING CLOSURE INSPECTION FORM <br /> SITE NAME: SR#: 0017g0 <br /> ADDRESS: S a CITY: <br /> OWNER NAME: h PHONE. S70 S31 SS <br /> CONTRACTOR: a,^ PaOC14 .0 /nC, PHONE: 6 71 a o0 <br /> FIRE PERMIT#: A/A TANK#39 <br /> 13 PIPING REMOVAL ❑ UST REMOVAL ❑ CLOSURE IN PLACE ❑ TEMPORARY CLOSURE <br /> INSPECTOR: DATE: o 3 f 20 <br /> R RINSED: ❑YES NO METHOD: AMOUNT: /v 4- <br /> I <br /> N RINSATE DISPOSAL SITE: <br /> S <br /> E MANIFEST#: I 1 �1 OTHER TRACKING#: <br /> V Aj� <br /> A PURGED: *ES L3 NO METHOD: AMOUNT USED: <br /> P <br /> R READINGS AT REMOVAL: L.E.L.: d�J 02: COMMENTS*: Rq�/1p,fp gyp/ 1L <br /> `j a14 U <br /> C TANK MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TANK SIZE <br /> NIA- <br /> 0 TANK CONDITION: L3 GOOD Ll POOR L1 HOLES Comments*: 6y(,k5 Not- rettciejot, <br /> N <br /> S PIPE MATERIAL: ❑ STEEL ❑ FIBERGLASS ❑ OTHER TOTAL LENGTH OF PIPING <br /> T PIPE CONDITION: ❑ GOOD ❑ POOR ❑ HOLES Comments*: <br /> DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> T � � - <br /> A <br /> N <br /> K <br /> EXCAVATION SIZE: X X <br /> Length Ndth Depth <br /> S DEPTH SOIL TYPE OBSERVATION* SAMPLE# <br /> M I �l <br /> P P <br /> L E <br /> TRENCH SIZE: X X <br /> N ILength VAdth Depth <br /> G H DEPTH TO GROUNDWATER: �--'4NT #HOURS SINCE DEWATERING: WA <br /> 2 <br /> p SAMPLING METHOD: I\f OBSERVATION*: /v A, <br /> STOCKPILE#1: Cubic Yards COVERED: ❑YES ❑ NO SAMPLE# SAMPLE# OC;K <br /> STOCKPILE#2: Cubic Yards COVERED: ❑YES LINO SAMPLE# SAMPLE# <br /> OTHER SAMPLES: <br /> LABORATORY: Qlick SAMPLERS NAME: G-•-af(- <br /> CLOSURE IN PLACE: I BACKFILL MIXTURE: (J,� Q(� VOLUME: tf Ar <br /> SITE MAP ATTACHED**: YES ❑ NO <br /> EH 23-0043(Rev 512212007) IMPORTANT NOTES: Complete one form for each tank removed <br /> *Include all comments/observations **Site Map Required <br />